Mar 25 2013

Food – Please Sir, Can I Have Some More?

One of the biggest killers in the world is malnourishment. It’s a global issue and covers a variety of conditions affecting both the developed and the developing nations.

It’s a global phenomenon. Yes you did hear me right, we in the west have malnourishment issues just as much as we in the developing world face it but the faces of the two things are different.

First let’s discuss the developing world.

While we do have malnourishment in the traditional sense of undernourishment, the vast majority of malnourishment in the west is over nutrition or obesity.

There is a problem in society because doctors are caught up in the cultural war between fat “acceptance” and the fashion industry/celebrity industry which sets unfeasible standards of attraction through genetics, surgery and lifestyle that the average woman cannot achieve. This is now beginning to affect men because after years of being portrayed as chubby happy go lucky, the rise of the buff has resulted in more and more men being depicted with unfeasibly amazing bodies.

The problem is people associate any attempts to tell them to lose weight with the same industry that uses photoshop to “emphasise” or indeed turn people already considered attractive into something artificially beautiful. You can make the ideal woman and like the greek sculptures, the ideal body is near impossible to achieve unless you live in a world where you are paid exclusively to be fit. I hold no illusions that my physique is not the ideal even by medical standards. But I am trying to shed “Exam Weight” (No clinics so no standing, no exercise and comfort food). I have scars. I have bags under my eyes. Photoshop can cover those things up and it’s useful. My Visa photos don’t look like I just fell out of a police line up. My ID cards look professional even if I look sleep deprived. My photos don’t suffer from the tell tale shine of dark skin… But when you take an already attractive human being and emphasise their attributes to create a standard of attractive that cannot be achieved then you start causing people issues. If you then demand that only people who meet this standard are attractive and that if you cannot then you are a failure then we start having problems.

But that’s not what doctors are on about. We want you to be healthy because it’s in your best interest to be healthy. And for that we have a tool called BMI. BMI is a simple, quick test to determine obesity. It’s pretty accurate for determining if a person needs to lose weight or not. Unless you are insanely fit (We are talking Olympian or Professional Athelete) chances are BMI applies to you. I have heard everything from BMI not being accurate to BMI being a tool of dieting corporations. I have had people so obese that we needed to use special tables and ambulances to bring them in claim that BMI was a hoax…

So the explanation is this. BMI is inaccurate. Just not in the way you think it is. 99% of people who it says are overweight are overweight. The problem is that the people who it says are normal may be overweight. If we utilised a body fat meter a fair few more people would be counted as overweight.

The fact remains that obesity is unhealthy and telling people to lose weight is part of our jobs as doctors. If we are to “not discriminate” against fat then we cannot discriminate against sugar or salt or cigarettes. Being obese is a medical problem and many drugs and procedures are complicated by obesity. And a lot of medicine is lifestyle modification. Wearing shoes, cleaning your drinking water and eating sensibly and doing exercise… Yes, there are some people who are obese due to medical issues but you cannot tell me that 30% of the USA and 20% of the UK are obese because of hypothyroid conditions? And bear in mind the level of excuses I have had from “he’s a growing boy” (for a 4 ft 11, 11 year old who weighed 110 Kg) to a man who claimed his obesity was due to a condition called PCOS.

Losing weight is hard. I am struggling to do so. In fact my exercise routine has been wrecked by my knees getting twatted but I try and walk a mile a day at least and play with the dog or try and go swimming. I try and cut down on the carbs and fats in a country where carbs and fats are considered staples and where obesity is only now being treated as a problem rather than a sign of wealth. Where often my diet consists of rice, lentis and clarified butter. A mix guaranteed to turn you spherical…

But the thing is obesity is a form of malnourishment and it should be fought. We aren’t trying to ensure our children are supermodels and we should allow them to eat the things they like, but we are their role models and the things they like should be moderated by the things they NEED. And what they need is a balanced diet and exercise juxtaposed with the Happy Meals and Candy.

But enough about that. Let’s talk about the developing world. Bear in mind many of my patients have seen Man vs Food, a show where a man eats enough protein to last a month not because it tastes nice but because it’s a challenge. He puts himself in physical pain to consume ridiculous amounts of calories and protein in a display that’s nearly pornographic to people who couldn’t afford a single dish he eats between them.

Undernutrition is one of the biggest development challenges faced because it’s effects are long term and subtle. The key here to remember is this. It’s not just the skeletal children who are at risk, you can be undernourished and look “normal” for a long long time.

The appearance of normalcy is deceiving. Chronic and constant malnourishment has stunted their growth, brain development and immune systems. Today roughly 40% of all children under 5 in India are stunted in growth. They are short for their age. I know my parents developed in this situation too since I measure in at 5 ft 11. Average for a brit. Tall for an Indian though. Tall enough to smack my head on the doors of traditional houses and not fit in bus seats. This 40% is an indicator of chronic deprivation of food, care, play, water, sanitation and health care. By contrast around 5% of children are considered “starving” if we utilised the “emaciated” description.

Malnourishment in the first 3 years of life is a devastating problem. It not only increases the childhood mortality but also interferes with the foundation of development and growth. Body, Mind and Immunity are all compromised. The vast majority of childhood deaths occur in this period. In India 40 out of 1000 children die by the 1st year. By the 5th it’s 70 out of 1000. Roughly 60 out of every 1000 children die in the first 3 years of life.

It’s leaves terrible and visible scars on those it affects.

  • These children are more likely to get sick and childhood diseases are more severe. Prevention would stop a third of child mortality and India’s plans have dropped the Infant Mortality Rate from 70 per 1000 to 40 per 1000 often by simple improvements to maternal and child diet. Maternal and Child undernourishment causes approximately 3 million deaths per year.
  • Undernourished children are more prone to developing obesity later in life as chronic starvation results in late over-eating as the malnourishment disrupts the ability to control eating. It’s a survival mechanism except that we as humans have corrected starvation through scientific agriculture. So while such obesity used to be rare because starvation was countered by boom feasts, modern starvation is countered by steady food supplies and the sort of feasting associated with “coming off” starvation causes weight gain.
  • Children who are properly fed perform better at schools. This was demonstrated both in developed and developing nations and applies to both scales of the spectrum of food. Early starvation diminishes early learning and such children are forever forced to play catch up to well fed peers. In addition the quest for food is more important than education so parents don’t have time to educate their children if they are too busy keeping them fed. The reverse applies to western society where often schools and parents feed children food that is “junk”. High in sugar, low in fibre, it quickly passes through the digestive tract making you hungry again. It’s cheap, it’s easily available and kids love it. We feed them reconstituted chicken meat in chicken nuggets and potatoes shaped like smiley faces rather than real good honest food and our kids get fat on this high sugar, high salt and high fat diets. Such kids don’t pay attention in classes either. We can make good healthy balanced meals for our kids that get them eating real food if society as a whole takes a stand and doesn’t rely exclusively on the junk.
  • Long term malnourishment leads to increased mental health issues. It’s shown to precipitate anxiety and depressive states even when controlling for other compounding factors.
  • It costs money. Many developing countries lose sizeable amounts of GDP to rectifying and correcting the issues caused by malnourishment and honestly prevention is better than treatment. It’s cheaper, improves the work force, increases social mobility and adds to economic stability to reduce the causes of such malnourishment and it’s an investment for the future by creating healthy workers. On a purely utilitarian standpoint it makes sense to do.
  • Malnourished mothers have malnourished babies. It’s not just a single life that’s affected but can jump across them. Malnourished mothers have more mortality. Their children often have increased congenital disorders such as Spina Bifida and mental retardation but also fail to thrive as much.
  • Vitamin malnourishment is the biggest single preventable cause for bone malformation, connective tissue disorder and blindness.

It’s why India has one of the largest nutritional supplemental schemes on  the planet as part of the ICDS (Integrated Child Development Services) working to counter the effects of chronic undernutrition.

But it’s still an uphill battle.


  • Simple economic power does not stop malnutrition. It’s a factor but it isn’t automatic. Often improvements to economic power are associated with over-eating. Economic power is an improving factor but not on it’s own.
  • Information and knowledge is important. Most people in places where food is scarce don’t know why you should not over eat or why you should balance your diet. Things we take for granted are often not understood or seen as “wasteful”. Why would you eat “the empty calories” of a salad rather than more carbohydrates? To us we know food is definitely going to be available. To them it’s a frivolity.
  • There is a notion that the market will solve this situation which is simply impossible considering undernourishment is invisible, irreversible and intergenerational and costly while overnourishment is highly profitable.
  • Lastly and this is important… The demographics of developing nations. In the vast majority of western nations, our agriculture is heavily mechanised. Less than 10% of our population feeds the 90%. In India where a transition is occurring, 70% are involved in food production for 30%… And we produce food on such a vast scale that we actually CAN afford to feed it to our cattle. Our systems are so effective that a handful of farmers can outproduce entire villages in third world nations. In India the issue is the way land has been parcelled out. The rise in population is mainly rural and these people work in agriculture. So the land got divided between sons. But here is the problem. We know for a fact that mega-scale agriculture is profitable. So much so that we hammer down food prices even though we actively “waste” food. It’s in our interests as this excess food forms a strategic reserve. We often use this food as aid to third world nations undergoing massive famine… But this is basically what guarantees us from not starving. Even a “bad” harvest is nullified if you simply produce so much food that the harvest losses can be made up through bulk production. However this means that many third world farmers produce food at such an inefficient rate that it’s cheaper to send a ship to the USA or the UK and bring back staples. It’s the problem with serf scale (AKA self sufficiency plus a bit more) agriculture. Wheat’s profitable if you produce hundreds of tonnes, not if you struggle to produce one. So these farmers try their level best to stick with what they have done for centuries without realising that we in the west have done this before. We called it the Industrial Revolution. History notes the desolation of the countryside as serfs left their farms to work in factories and slums while the few larger land owners consolidated their farms into larger ones that got profitable as the sole providers of food. Think of it this way, a 3% increase in yield on $100 is $3. If that involves an extra hour of work then is it worth working an hour for $3? Now imagine doing that for $100 million. Do you think an hour or even a few weeks of work more is worth $3 million? And agriculture requires infrastructure and infrastructure is more effective on larger farms. The horrible fact of the matter is that many developing nation farmers have no future because the future is a non-agriculture society. The options are to wait until the population falls which will take centuries… Or a horrible and harsh upheaval like the Industrial revolution. Neither are good options and no one wants to make the terrible choice. But it’s the underlying cause of the myriad suicides from Indian farmers. Indian farmers desperately see the seeds we use and don’t see the value of the expensive infrastructure that the seeds need for our bumper yields. So they pick up the seeds often using loans from unscrupulous unofficial money lenders and end up in debt when the crop naturally fails. I know there is a love of blaming Monsanto but their seeds have to be sold in India with an Indian partner and the Indian partner is responsible for distribution. The packets may be clearly labelled but the farmer often has it implied to them that the seeds are “magic”. When the crop fails the farmer is literally at the end of his rope with no way out. This tragedy sadly requires the destruction of an entire tradition of agriculture of the serf/subsistence farmer in order to be stopped. This means hundreds of millions of people require new jobs in the case of India. An impossible task. The west having needed the bodies to operate the industry of the industrial age had those jobs but there was still incalculable sadness from this demographic shift. There is literally no right answer to this problem and things like start up micro-loans are producing small positive changes but the scale is monsterous. To put it into perspective? In India that’s a population the size of the USA needing to not exist (Because there are a finite amount of modern jobs). For the population to correct itself you either require a ridiculously draconian plan like the Chinese one or you need centuries. India’s population will stabilise in 2040 and fall from then but we are looking at more than a century from then to correct this issue. And remember with increased time the issue gets harder to correct as technology increases automation which means fewer jobs are needed to do a specific thing.

Public action has to occur on the following levels. We must scale up a set of proven nutrition interventions and design programmes that attack the underlying causes of malnutrition in agriculture, social welfare, education, women’s empowerment, water, sanitation and hygiene. And we must develop an enabling environment to advocate for and support these interventions through systems like micro-loans and cooperatives.

We need to improve education and agriculture in the rural sector. We need to provide healthcare and education with regards to family planning.

All these will fight malnourishment in the long run and improve the lot of the rural subsistence farmer and help increase the rate at which the demographics of underdeveloped and developing nations turn to developed nations and hopefully without the crash that most European nations underwent during their modernisation during the Industrial age.

As for us? Eat Smart and Do Some Exercise. It’s not a wish to see you meet an impossible standard it’s a wish to see you healthy.


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  1. 1

    A note about BMI: it was generated using a dataset of only men.

    Therefore is it is rather inaccurate, especially for short women, especially for short women with large boobs & butt like myself.

    I could stand to lose a few pounds, but I’m not, I don’t think, obese, as BMI says I am. I can run 3 miles easily and have excellent pulse rate, blood pressure, and cardiovascular health.

    I wish doctors would stop using BMI as a tool to diagnose individuals, because that is not how it is intended to be used. And I wish they would update the dataset.

  2. 2

    My understanding is that BMI was intended for analysis of populations rather than individuals but it can still be used as a guide.
    I didn’t know it was modeled only on men rhough., that’s a major failing if true.

    Why will India’s population stabilise is 2040?

  1. 3
    Thieves of Potential » A Million Gods

    [...] V is 12 years old and came to see me today. And V is a classic example of “chronic starvation“. [...]

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